What are the management options for colitis?

Management of Colitis

The treatment of colitis depends on the type, severity, and extent of disease, with first-line therapy for mild to moderate disease including oral mesalazine (2-4g daily) or balsalazide (6.75g daily). 1

Types and Classification of Colitis

Colitis management varies based on etiology and severity:

Assessment and Classification

• Severity grading:

  • Grade 1: Increase of <4 stools per day over baseline; mild increase in ostomy output
  • Grade 2-4: Moderate to severe symptoms requiring more aggressive management 2

• Diagnostic workup:

  • Laboratory tests: CBC, CRP, ESR, serum electrolytes, albumin, liver function tests 1
  • Stool studies: Culture, C. difficile testing, parasites, viral pathogens 2
  • Imaging: CT with IV contrast for suspected complications 1
  • Endoscopy: Essential for diagnosis and assessing disease severity 2, 1

Treatment Algorithm by Severity

Mild Disease (Grade 1)

1. Continue immunotherapy if applicable (for immune-related colitis) 2
2. Oral mesalazine (2-4g daily) or balsalazide (6.75g daily) 1
3. For distal disease: Combination of oral and topical mesalazine 1
4. Supportive care:
   • Loperamide if infection ruled out
   • Monitor for dehydration
   • Dietary modifications 2
5. Monitoring: Close follow-up every 3 days until stabilized 2

Moderate to Severe Disease (Grade 2-4)

1. Oral prednisolone 40mg daily with gradual taper over 8 weeks 1
2. For severe disease: IV steroids (hydrocortisone 400mg/day or methylprednisolone 60mg/day) 1
3. For steroid-dependent disease: Azathioprine (1.5-2.5 mg/kg/day) or mercaptopurine (0.75-1.5 mg/kg/day) 1
4. For steroid-refractory disease: Infliximab or cyclosporine 1
5. Consider inpatient care for Grade 3-4 2

Immune Checkpoint Inhibitor-Induced Colitis

1. For Grade ≥2: Consider permanently discontinuing CTLA-4 agents 2
2. May restart PD-1 or PD-L1 agents if patients recover to Grade ≤1 2
3. For refractory cases: Infliximab or vedolizumab 2

Biological Therapy

Infliximab (5 mg/kg at 0,2, and 6 weeks, then every 8 weeks) is indicated for:

• Moderate to severely active Crohn's disease with inadequate response to conventional therapy
• Ulcerative colitis to reduce signs and symptoms, induce and maintain remission 3

Important safety considerations:

• Screen for tuberculosis and treat latent TB before starting infliximab
• Monitor for serious infections during treatment
• Risk of lymphoma and other malignancies, particularly in young males with Crohn's disease or ulcerative colitis on concurrent immunosuppressants 3

Special Considerations

Antibiotic Use in Colitis

• Metronidazole 400mg TID and/or ciprofloxacin 500mg BID for fistulating disease 1
• Consider antibiotics when infection is suspected 1

Surgical Intervention

Indications for surgery:

• Free perforation
• Life-threatening hemorrhage
• Generalized peritonitis
• Toxic megacolon with clinical deterioration
• Failure to respond to medical therapy within 48-72 hours 1

Procedure of choice: Subtotal colectomy with ileostomy for severe disease 1

Maintenance Therapy

• Lifelong maintenance therapy generally recommended to prevent relapse 1
• Options include:
  • Oral mesalazine 2-4g daily
  • Azathioprine or mercaptopurine
  • Biologics for more severe disease 1

Common Pitfalls and Caveats

1. Delayed recognition of severe disease requiring surgical intervention
2. Inadequate dosing of 5-ASA compounds
3. Prolonged steroid use without appropriate steroid-sparing strategies
4. Failure to recognize infectious causes of colitis
5. Avoiding opioids when possible due to risks of dependence, infection, and gut dysmotility 1
6. Not considering a multidisciplinary approach with gastroenterology and surgical consultation for severe disease 1

Monitoring and Follow-up

• Regular surveillance colonoscopies to monitor disease and screen for dysplasia/cancer 1
• For severe disease: Daily monitoring of vital signs, stool frequency, and laboratory parameters 1
• Consider fecal calprotectin to follow disease activity 2, 1
• Mucosal healing on repeat endoscopy and/or fecal calprotectin level ≤116 mg/g can guide decisions on when to stop biologic treatment 2